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The International Olympic Committee (IOC) and international sports federations have recently introduced policies requiring medical investigation of women athletes known or suspected to have hyperandrogenism. Women who are found to have naturally high testosterone levels and tissue sensitivity are banned from competition unless they have surgical or pharmaceutical interventions to lower their testosterone levels.

The primary justification offered seems to be one of reducing unfair advantage, with a secondary justification that investigations of this sort might be to the medical advantage of the athletes themselves. Rebecca Jordan-Young and her colleagues aren’t impressed, and think that the policy is ethically suspect: not the least of their worries is that the policy effectively medicalises an unusual but benign characteristic of some people. This could lead to medically useless surgery. However, the potential problems are wider than that:

When pharmacological intervention or gonadectomy is a precondition for eligibility to compete, an athlete has to make a profound life and health altering decision for non-medical reasons. These are not merely individual decisions: athletes are embedded in families, teams, organisations, and even nations that depend on them to compete. Athletes can be “regarded as vulnerable to undue, even extreme situational pressures arising from the decision-making environment,” especially when a competitive career is also a path to economic mobility and stability.

I have to admit that I’m fairly relaxed about surgical interventions being undergone for non-medical reasons; but even given that, they would have to be undergone for good reasons, and defensible reasons. It’s not clear that those conditions’d be met in this example – especially given the worries about tacit coercion given the pressure put on some women to compete as a means to provide stability and/ or national prestige. I guess that making sacrifices – sometimes quite big sacrifices – is a part of elite athletics training, and there might be times when big sacrifices might be demanded of a person for some reason; but it doesn’t follow that it’s justified to expect women to have surgery as a precondition of competition. The article finishes with a comment that I think is particularly interesting, though, and one that points to something about the policy that is not just morally questionable from an external point of view, but also from an internal one. (By this, I mean that a sine qua non of any policy, regardless of the merits of its content, is that it be coherent.) Here’s the comment:

Women athletes will continue to be identified as having high testosterone levels through universal anti-doping screening. When testosterone is high because of natural physiological variations, sports authorities should not require medical interventions to lower it. The interventions are too serious, especially given that sports officials have said, “Women with some DSDs [disorders of sex development] have no more competitive advantage than other elite athletes with favourable genetic characteristics.” The testosterone based eligibility policies turn standard medical decision making about hyperandrogenism on its head. Rather than pegging treatment decisions to women’s overall wellbeing, symptoms, fertility goals, self image, physical functioning, and risks (if any) associated with a specific diagnosis, intervention is mandated when officials decide that naturally occurring testosterone confers unfair advantage. This seems to undermine ethical care.

I think that, notwithstanding my ease with non-medical surgery, I’d happily sign up to this position; but I think that it’s worth raising a couple of other points, too. The first has to do with the nature of sports medicine; the second has to do with the nature of sport. Here’s the sports medicine point. Jordan Young et al seem to me to be taking a “standard” medical approach to sports medicine: for them, treatment is pegged to “overall wellbeing”. For the most part, that seems to me to be what medicine is about. However, I’m not sure that overall wellbeing can possibly be the end of sports medicine. The reason for this is that, at elite level, the kind of performance required is not contributory to wellbeing – rather, things’re the other way around. While Joe or Joanne Average could probably stand to do a bit more sport for the sake of their health, the kind of sport that Joe and Joanne Athlete do requires that they be healthy already. More: an elite athlete can reasonably expect a range of injuries that the rest of us will almost certainly never risk. An elite career may be glorious, but there’s a higher-than-average risk that it’ll end with stress-fractures and naffed-up joints. As such, if sports medicine is pegged to overall wellbeing, it’s not implausible that sometimes the best medical advice would be to settle for going jogging a few times a week. Now, of course, we could interpret wellbeing widely, and say that there’s more to it than health: that the achievement of glory is part of it; and that sports medicine is therefore a perfectly acceptable part of achieving glory. But then it becomes hard to see why a woman with unusually high levels of testosterone is a problem: running 10 kilometres in less than half an hour is pretty glorious irrespective of what molecules are bumping around your body. Deny that, and you’re opening the door to saying that there should be separate categories not only for male and female athletes, but for every conceivable variation of abormal chromosome and androgen sensitivity. But if you’re willing to make a difference there, then why not for any other genetic quirk that might make a difference? In other words, you’re faced with absurdity. And this leads us to the question of the nature of sport – particularly in respect of fairness. Why should abnormally high testosterone constitute an unfair advantage? An advantage, yes. An unearned one, yes. An unfair one? That’s harder. On one level, I suppose it is unfair – but no more unfair than the fact that some people have bodies that are just better at running, or jumping, or swimming, or whatever: it’s not unjust, for any of that. As such, it doesn’t seem to require remedy. Indeed, remedy might itself be absurd. After all, it seems to me that part of what we’re doing when we watch a race is expressing an interest in, and admiration for, physical excellence of a certain kind, in which context excellence is simply a matter of being fast, or strong, or flexible, or whatever. We want to know who’s the best. Some of that excellence is a matter of brute genetic luck. Trying to medicate that away, it seems to me, takes away an element of what the point of sport is in the first place.

“I’m fairly relaxed about surgical interventions being undergone for non-medical reasons” – presumably one of the preconditions for non-medical surgeries on competent adults is that they themselves desire the surgery? Not sure I’m with you on the issue of the end/aim of sports medicine (seems to me that it remains well-being, just that what counts as well-being for sports people is more likely to include certain norms that are different from those of non-sports people, same goes for palliative medicine etc). Though it’s not something I’m overly concerned with. Far more important is the notion of unfair advantage and the particular focus on gender-atypical advantages.

The IOC doesn’t focus on any other conditions that confer an athletic advantage. I’m not only disturbed by this policy because it imposes an unnecessary medical risk (with whatever side-effects) but because it imposes it only on a small proportion of athletes who have a natural advantage. It is problematic because of the external coercive elements you highlight (pressure to seek stability, prestige for home country etc) and also because it this ‘unfair’ advantage prevention policy would be disproportionately applied to athletes who are perceived to deviate from the norms of their sex. This is really an instance of intersexphobia.

I think that there’s a load of really interesting questions to be asked about where and why sports draw distinctions between “types” of athlete – whether that be male/ female, olympian/ paralympian, or whatever; and the intersex aspect is part of what got me thinking about that. I’m not sure I’d call it “intersexphobia” – but it’s something much more nuanced than the current rules seem to be able to accommodate.